# Healthcare-Associated Ventriculitis and Meningitis Summarizing **strong recommendations** from the 2017 IDSA’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis^[Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, Van De Beek D, Bleck TP, Garton HJL, Zunt JR. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis*. _Clinical Infectious Diseases_. 2017;64(6):e34-e65. doi:[10.1093/cid/ciw861](https://doi.org/10.1093/cid/ciw861)] Risk for meningitis after craniotomy significantly increased with^[Kourbeti IS, Vakis AF, Ziakas P, Karabetsos D, Potolidis E, Christou S, Samonis G. Infections in patients undergoing craniotomy: risk factors associated with post-craniotomy meningitis. _Journal of Neurosurgery_. 2015;122(5):1113-1119. doi:[10.3171/2014.8.JNS132557](https://doi.org/10.3171/2014.8.JNS132557)]: - perioperative steroid use (OR 11.55, p = 0.005) - CSF leak (OR 48.03, p < 0.001) - ventricular drainage (OR 70.52, p < 0.001) > The 3 most common pathogens in neurosurgical infection come from the skin: > 1. Staph (Staph A and coag-neg Staph) > 2. Strep > 3. C Acne ## Signs and Symptoms - Fever - Headache, meningeal irritation, seizures, and/ or worsening mental status - Erythema and tenderness over tubing - VPeritoneal, VPleural, or VAtrial shunts: peritonitis, pleuritis, or bacteremia, respectively ## Diagnosis - Culture of both CSF and infected equipment before giving antimicrobial → infection is likely if patient is symptomatic and there is one of the following culture findings: - Positive culture paired with CSF pleocytosis and/or hypoglycorrhachia - Staphylococcus aureus or aerobic gram-negative bacilli growth - Fungal pathogen growth - β–D-glucan and galactomannan - VA shunt: add blood culture - Imaging: - MRI w/ contrast + DWI - VP shunt: Abd US/ CT for CSF loculation > Negative CSF gram staining does not rule out an infection (esp if patient received antimicrobial before testing) > If suspicion for infection is high but culture returns negative, keep culture for 10+ days for potential *Propionibacterium acnes* ## Treatment - Source removal - Empirical antimicrobial, ref [[Surgical Antibiotics]] - Vancomycin (trough at 15 ug/mL) + an anti-pseudomonal beta-lactam (such as cefepime, ceftazidime, or meropenem) - If anaphylatic to β-lactam: aztreonam or ciprofloxacin - If there's an abscess: metronidazole > Always adjust the regimen to address other antimicrobial-resistant pathogen that the patient might carry. - Agent specific antimicrobial: | Organism | First-line Antimicrobial | Alternative | Note | | ---------------------------------------------------------------------- | ----------------------------------------------------- | --------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------- | | MSSA | Nafcillin or oxacillin | Vancomycin (if patient cannot receive beta-lactams) | 3rd line: Linezolid, daptomycin, or trimethoprim-sulfamethoxazole (based on susceptibility) | | MRSA | Vancomycin | Linezolid, daptomycin, or trimethoprim-sulfamethoxazole (based on susceptibility) | Consider alternative if vancomycin MIC ≥1 μg/mL | | Coagulase-negative staphylococci | Similar to S. aureus, based on susceptibility testing | | | | Staphylococci (with intracranial/spinal hardware) | Rifampin combination therapy | | | | Propionibacterium acnes | Penicillin G | | | | Gram-negative bacilli (susceptible to third-generation cephalosporins) | Ceftriaxone or cefotaxime | | | | Pseudomonas species | Cefepime, ceftazidime, or meropenem | Aztreonam or fluoroquinolone | | | Extended-spectrum beta-lactamase-producing gram-negative bacilli | Meropenem | | | | Acinetobacter species | Meropenem | Colistimethate sodium or polymyxin B | | | Candida species | Liposomal amphotericin B ± 5-flucytosine | | | | Aspergillus or Exserohilum species | Voriconazole | | | > Agent selection: Always select for agents with great CNS penetration, though these agents may worsen mental status and/ or induce seizures. > Duration: Aim to treat for 10 days **following the last positive culture**; 14 days with significant systemic symptoms and/ or CSF pleocytosis/ hypoglycorrhachia > If patient is not responding to systemic antimicrobial, consider intraventricular therapy--- adjusted for 10-20 times the MIC of the causative organism, ventricular size, and drain output. Clamp the drain for 15+ minutes after dosing to equilibriate the drug. > To track response to treatment, perform serial monitoring of clinical symptoms and CSF cultures. ## Reimplantation | Infecting Organism | Clinical Scenario | Reimplantation Timeline | | | -------------------------------------------- | ------------------------------------------------------------------------------- | ------------------------------------------------------------ | --- | | Coagulase-negative staphylococci or P. acnes | No CSF abnormalities + negative CSF cultures for 48 hours after externalization | 3+ days after explant | | | | With CSF abnormalities + negative repeat CSF cultures | After 7 days of antimicrobial therapy | | | | With CSF abnormalities + positive repeat CSF cultures | After CSF cultures remain negative for 7-10 consecutive days | | | S. aureus or gram-negative bacilli | Any | 10 days after CSF cultures are negative | | > No need to verify for clearing of infection while off of antimicrobial therapy before reimplanting the shunt. ## Recommendation for infection prevention - Periprocedural prophylactic antimicrobial - Antimicrobial-impregnated shunts - Repair basilar skull fracture and CSF leak lasting more than 7 days - Pneumococcal vaccination #clinicalscience #Neurological #guideline